Urogynae and Menopause

Question 1

Stress incontinence surgical management:

Answer 1

Urethral bulking agents
• Benefits – no incision, low risk, best for intrinsic sphincter deficiency,
• Risks – highest recurrence, need for repeat, urethral injury, need for self catheterisation
Transvaginal mid urethral tape
• Benefits – gold standard for SUI with 90% success rates
• Risks – infection, bleeding, bowel/ureteric injury, de novo detrusor overactivity, voiding dysfunction, dyspareunia, chronic UTI, mesh erosion, fistula, thigh pain (transobturator only)
Burch colposuspension (the bladder neck is lifted, vagina is attached to the ligament behind the pubic bone with sutures and this will lift and support your bladder neck which helps it resist increases in abdominal pressure)
• Benefits – avoid further vaginal incision, good continence rates (90% at one year, 70% at 5 years), no mesh risks
• Risks – as above without mesh risks, risk of posterior vaginal wall prolapse due to angulation of vagina.

Question 2

Pelvic organ prolapse management:

Answer 2

o Lifestyle advice
 avoid heavy lifting
 avoid straining (give laxitives)
 weight loss
o Conservative
 pelvic floor muscle physiotherapy – may improve symptoms or early stage prolapse but does not alter prolapse severity
 Ovestin cream for vulvovaginal atrophy and dyspareunia
 Offer pessary
• Type - ring for anterior prolapse, space occupying (shelf or cube) for vault prolapse
• Risks include erosion, infection, discomfort, failure.
o Surgical options
 Anterior repair + SSF
 Abdominal (laparoscopic or open) sacrocolpopexy/hystopexy
 Colpocleisis not appropriate given patient wants to continue having intercourse

Question 3

Overactive bladder management:

Answer 3

 Conservative – avoid bladder irritants, 1.5L fluid balance, bladder retraining, biofeedback
 Medical
• Anticholinergics - oxybutynin or solifenacin – side effects include dry eyes/mouth, constipation, long term risk of dementia. Aim for short term use only.
• B3 adrenoceptor agonist - Mirabigron – can cause hypertension, renal and liver impairment
 Electrical
• No routinely recommended
• TENS/PTNS - offer last resort
 Surgical – botox, clam cystoplasty, detrusor myomectomy, ileal conduit

Question 4

Anterior Repair Steps:

Answer 4

• Consent
o Bleeding
o Infection
o Damage to bladder
o Dysparunia, vaginal narrowing
o Recurrence
o Voiding dysfunction
o Buttock ache
• Steps of Anterior Repair
o Pre-Op
 Consent
 Anaesthetic assessment
 WHO sign in
o Intra op
 Anaesthetic
 Position in dorsal lithotomy
 Check allergies and antibiotics (not routinely required)
 VTE prophylaxis
 Prep and drape
 WHO Time Out
 Do not place IDC at start of procedure
 EUA to reassess POP-Q score now fully relaxed with anaethetic
 Place Allis forcep on anterior vaginal wall in the midline 1-2cm from urethral meatus
 Place second Allis forcep on the anterior vaginal wall in the midline as proximal as possible beyond the most distal portion of the prolapse
 Assistance to hold allis forceps superior and inferiorly to put vaginal mucosa under tension
 Infiltrate local anaesthetic in the midline to elevate mucosa off underlying fascia and extend infiltration laterally on each side
 Use scalpel to cut vaginal mucosa longitudinally between each allis forcep
 Place new allis forceps on free edge of vaginal mucosa on one side to elevate it off the fascia. Dissect the mucosa off the fascia (can be blunt with small gauze wrapped over a finger if no previous surgery or may need to be blunt with fine tissue forceps angled towards the mucosa). Repeat on opposite side until paravaginal fasica is reached.
 Plicate the fascia using interrupted 2.0 pDS leaving each suture untied and long and attached to a small artery clamp
 Sequentially tie off each suture starting with most proximal in the vagina.
 Ensure haemostasis
 Assess need to trim vaginal mucosa. Do not perform excessively to avoid undue tensions on repair increasing risk of breakdown and vaginal narrowing
 Repair vaginal mucosa continuously with 2.0 vicryl
 IDC + pack
o Postop
 Document
 discuss follow-up: analgesia, pelvic rest 4-6 weeks, ovestin cream, no heavy lifting 4-6 weeks, clinic 4-6 weeks

Question 5

Bioidentical Creams for menopause

Answer 5

● Bioideinticals and compounded creams not recommended as no evidence to prove efficacy, other preparations have sound clinical evidence. Also as not commercially prepared have varying levels of active hormone.
● Needs oestrogen + progesterone for endometrial protection
● No CI to HRT in history
● Can take HRT up to 10y and <60 in general with minimal risk
● Appears to have a cardiovascular benefit in younger women at least for first year, though NOT indicated for prevention
● Options for treatment
o COCP eg Ava 20
o E2 with cyclical progesterone (CEE or E2 or patch with MPA or micronized PG or mirena)
o If problems with PG Sx might try continuous
● May have bloating/breast pain
● May have resumption of Sx on stopping
● Written information

Question 6

When to use mesh in urogynae:

Answer 6

Not supported as first line
MDT approach
Fully inform woman risk of chronic pain associated = 1-3% Mesh erosion = 2% Permeant structure may be difficult to remove.
Submit case for clinical audit purpose
Refer appropriately trained sub specialist urogynaecologist

Question 7

Colpocleisis:

Answer 7

An obliterative procedure done vaginally to support pelvic organs
Success >90%
Quick procedure and recovery
Can be done under local anaesthetic if required
~30% stress urinary incontinence following procedure
No longer sexually active
Cervix and endometrium no longer accessible screen pre-op

Question 8

Posterior repair:

Answer 8

reinforce the weaken layers between the rectum and vagina
Success rates 80-100%
Constipation
Dysparunia
Injury to rectum 
Vaginal shortening
Pudendal neurology
Don’t recommend pregnancy post

Question 9

Anterior repair:

Answer 9

reinforce the weakened layers between the bladder and vagina
Increased rate of recurrence if uterus preserved
Future pregnancy not recommended
0.5-2% injury to adjacent structures
Risk of retention, UTI, de novo stress/urge incontinence
Risk of dysparunia

Question 10

Urogynae & POP exam and initial investigations:

Answer 10

POP-Q
Urine dip and MSU
Post void residual 
Urodynamics (not if pure stress)
Pelvic floor muscle tone
Measure genital hiatus and perineal length 
Q tip test for urethral hypermobility
Elicit stress symptoms with cough test
Bladder diary

Question 11

Management of POP conservative:

Answer 11

Weight loss 
Smoking cessation
Treat constipation
Avoid heavy lifting >5kg
Pelvic floor muscle training improvement of symptoms at 6 months 10 contractions TDS holding 5secs 
Topical oestrogen 
Pessary

Question 12

Vaginal hysterectomy and vault suspension:

Answer 12

~85% success rate
Faster return to normal activity and less complications vs open and lap
~10% vault heamotoma, infection, UTI
2% risk damage to surrounding structures
40-45% de novo incontinence
Risk of fistula

Question 13

Abdominal sacrocolpopexy/ lap approach:

Answer 13

success 76-100%
4.1% reoperation rate
Lower rate prolapse recurrence vs SSF
Reduced dysparunia
Less post op SUI
Longer recovery, operating time compared to vaginal routes

Question 14

Sacrospinous fixation:

Answer 14

Success 67-97%
Recurrence 2-19%
Post op buttock pain
De novo SUI
Pudendal nerve injury (vaginal pain, problems with bowel and blader)
Sciatic nerve irritation
Increase anterior compartment prolapse recurrence 
Temporary ureteral obstruction

Question 15

Pessary fitting:

Answer 15

With chaperone and consent:
• Empty bladder
• Dorsal litotomy
• Pelvic examination:
o Skin condition – rashes, postmenopausal changes\
• POP_Q:
o Introitus (gaping)
o Perineal body
o Descent with valsalva – perineum supported or not, anterior/posterior/vault/uterine prolapse
o SIMS speculum in left lateral assessing extent of descent and locaitons
• Decide which pessary most suitable – ring/shelf/sub-urethral support/gelhorn/cube
• Bimanual
o Masses, descent, approximate length from posterior fornix to posterior aspect symphasis pubis
• Select pessary size
• Ovestin
• Ring: Fold pessary in half
• Gently part labia
• Insert pessary, curve DOWN
• Fit behind symphisis
Stand woman up, ask her to squat a few times
If comfortable – can get dressed
Have water/cup of tea in waiting room, make sure can pass urine and walk around comfortably
Review 3 months unless problems earlier (pain/bleeding/expulsion/unable to PU/new incontinence)

Question 16

When would you do Urodynamics in stress urinary incontinence:

Answer 16

1. Urge-predominant mixed incontinence or type is unclear
2. Symptoms suggestive of voiding dysfunction
3. Anterior or apical prolapse
4. A history of previous surgery for stress incontinence

Question 17

Management of urinary incontinence

Answer 17

Lifestyle Weight loss

• Offer dietician referral
• Can improve UI

Fluid intake
- Reduce to 1-1.5L/day
Avoid tea, coffee, alcohol – can irritate bladder
If nocturia an issue, reduce fluids in the evening

Bladder retraining Usually done through PT
Aim to pass more urine less frequently
Bladder drill outcomes:
· 90% continent and 83.3% symptom free after 6/12 (compared to 23.2% in control group)
· 40% relapse within 3y

Pelvic floor exercises
Increases strength of pelvic floor muscles, leading to improved control of urine leakage

Topical oestrogen
· May improve atrophy and increase sensory threshold of the bladder

Medications
Review current medications – some meds increase urine production, e.g. diuretics
- Sedatives can worsen OAB symptoms
Anticholinergics (oxybutynin)
- reduce OAB symptoms by up to 75%
- Inhibit detrusor contraction
- Side effects – dry mouth, constipation, blurred vision
- Concern around impact on cognitive ability, try use for short term only (1y then break)
Mirabegron (Betmida) beta 3 –adrenoreceptor agonist

Question 18

Treatment of VIN:

Answer 18

Surgical e.g. wide local excision
 Best for those at increased risk of invasive disease (previous VIN or vulvar carcinoma, immunosuppression, tobacco use, age >45yrs, history of lichen sclerosus)
 Recommended in differentiated type at 30% risk of progression to cancer
 Provides histological specimen, curative intent
Ablative therapy e.g. laser vaporisation
 Young women, multifocal disease lesions involving clitoris, urethra, anus or vaginal introitus (excision –> dyspareunia)
 Cosmetic advantage as superficial, results in less dyspareunia (if sexually active)
Pharmacological therapy e.g. Imiquimod
 Topical treatment - can apply at home
 Avoids surgery - option for medically co-morbid patients who are poor surgical candidates
 Useful if multi-focal as above
 Consider for recurrent lesions to reduce anatomical distortion (preserves anatomy) with multiple excisional procedures

Question 19

Symptomatic prolapse

Answer 19

Management
1.Conservative
a. PFMT with PT
b. Ovestin cream twice weekly
2. Medical
a. Pessary – needs to be reviewed at least every 12 months and must use ovestin cream twice weekly
3. Surgical
a. Anterior repair + vaginal hysterectomy +/- SSF if indicated
b. Anterior repair + sacrohysteropexy if wanting uterine conservation
c. Briefly discuss risks with vaginal surgery
–
new incontinence, bleeding,
infection, damage to surrounding structures, recurrence

Question 20

Menopause well woman check

Answer 20

Lipids, Cholesterol, HbA1c, yearly BP check
DEXA scan, weight bearing exercise, Vit D and calcium supplementation
Mammogram 45 to 69 every two years
Cervical smear three-yearly from age 25 to age 69.

Question 21

Stress incontinence management

Answer 21

Medical:
1. Knob pessary
Surgical:
1. Urethral bulking
2. Mid urethral sling (TVT, rectus fascial sling) – risk with mesh discussion
3. Burch Colposuspension

Question 22

Overactive bladder

Answer 22

Medical:
1. Commence on oxybutynin - discuss side effects (dry mouth, postural hypotension
a. If oxybutynin unsuccessful, solefenacin
b. Mirabegron
2. PT nerve stimulation
Surgical
3. Bladder botox – risks with this including intermittent self-cathetrisation
4. Sacral neuromodulation

Question 23

Paget’s disease of the vulva

Answer 23

pruritic rash - velvety red with dotted white islands
Extramammary pagets disease is an intra epithelial adenocarcinoma that accounts for less than one percent of all vulvar malignancies

Generally affects those in 60-70s and usually Caucasian

Typically present with pruritis and eczematoid skin change on the vulva with well demarcation raised lesions on a red background often dotting with small pale islands

Invasive adenocarcinomas may occur in 4 - 17%

Synchronous neoplasms occur in 20-30% typically involving breast, colon, bladder, gallbladder, cervix, ovary, breast, uterus

Therefore need to exclude these - cervical smear, mammograph, colonoscopy, cystoscopy, abdomino pelvic imaging (USS or CT)

Book for surgical excision

Question 24

When is a DEXA scan indicated

Answer 24

Bone DEXA recommended for all women >65yrs AND younger postmenopausal women with one or more risk factors other than being white or menopausal;

Asian or Caucasian

Age

Previous hx fragility #

Family hx fragility #

Smoker

Low BMI

Family hx osteoporosis

Amenorrhoea

Calcium or vit D deficiency

Use of bone losing meds

Sedentary lifestyle

Excessive use of alcohol

Rheumatoid arthritis

Early menopause

Question 25

Surgical principles of vulvar paget’s

Answer 25

Wide excision of lesion or vulvectomy

2 cm margin preferred

Primary closure of vulva if too large then use flaps or skin graft

Intraoperative frozen section on lines of excision (accuracy associated with this is poor ~30%)

Preserve midline structures if feasible

Needs follow up 3 -6 monthly as recurrence is common (30-50%). Recurrence usually requires further surgery.

Also needs regular ongoing surveillance for synchronous tumours

Question 26

Management of a vaginal hematoma post op

Answer 26

Aim to manage conservatively in the first instance

Recatheterise and replace vaginal packing for tamponade

Commence broad spectrum antibiotics

Administer TXA 1g IV

TEDS and SCDS

Reassess in 1-2 hours

Surgical management in form of EUA + evacuation of haematoma if haemodynamically unstable from suspected ongoing blood loss or sepsis needing source control

Question 27

TVT

Answer 27

Preop – anaesthetic rv, HCG neg, preop bloods, safety checklist, IV abs, IDC, VTE prophylaxis, anaesthetic

Position patient in lithotomy

Identify urethra and infiltrate local anaesthetic subcutaneously to achieve hydrodisseciton

Make a 1cm horizontal incision 1-2 cm proximal to urethral meatus

Blunt dissection should be performed lateral to this incision on each side

Trochar should be introduced through the incision, aiming for the retropubic space and ‘hugging’ the pubic bone in order to avoid the bladder, and should then exit through the skin. Repeat on the other side.

Tension of tape should then be adjusted, ends should be trimmed/ trochars cut off

Vaginal mucosa closed over the top of tape

Cystosocpy performed

Postop - Document, VTE prophylaxis & GOPD 6 weeks

Question 28

Feacal incontinence

Answer 28

Rectal exam = to feel sphincter bulk and tone 

Referral to Colorectal surgeon, consider endoanal USS and nerve conduction studies

Question 29

Vaginal hysterectomy

Answer 29

Preop – anaesthetic rv, HCG neg, preop bloods, safety checklist, anaesthetic, IV abs, IDC, VTE prophylaxis,
Position in dorsal lithotomy
Grasp anterior lip of cervix with valsallum.
Infiltrate cervix with dilute local anaesthetic with adrenaline – circumferentially at junction of vaginal mucosae and cervix.
Make circumferential incision around cervix,
Dissect anterior to reflect bladder and repeat at posterior aspect to enter the para rectal space.
Perform an anterior and posterior colpotomy to enter the uterovesical and POD space.
Clamp, cut and tie off uterosacral ligaments bilateral – leave tie long.
Skeletnise the uterine vessels, clamp, cut and ligate bilateral, and repeat with the ovarian ligaments. Remove specimen. Assess haemostasis.
Secure uterosacrals to posterior aspect of vaginal vault. The vault is closed.
Postop - Document, VTE prophylaxis & GOPD 6 weeks

Question 30

Sacrospinous Fixation

Answer 30

Posterior vaginal wall is opened in the midline as for posterior repair.

Right pararectal space entered to access the ischial spine. Blunt dissection and lateral sweeping movements used

cardinal ligament containing the ureter retracted anteriorly

Sacrospinous ligament identified and exposed

A permanent or delayed absorbable suture is placed in the mid portion of the sacrospinous ligament 2-3cm medially from the ischial spine using the Capio needle

Repeat with second suture if unilateral procedure. Repeat same procedure on the opposite side if bilateral procedure.

Suture secured to the under surface of the vaginal vault or cervix and tied to reduce prolapse. Permanent suture material must be buried

Vaginal mucosa closed with continuous locked suture

PR examination performed

Vaginal pack and IDC are placed

Question 31

Posterior Repair

Answer 31

An incision is made to the posterior wall of the vagina.
Dissection below the vagina identifies the rectovaginal fascia and opens the space between the rectum and the pelvic floor muscle to the sacrospinous ligaments.
Defects in the fascia are corrected by centrally plicating the fascia using sutures.
The stitches can strengthen your tissues in two ways: first, by closing any tears, and second, by encouraging scar tissue to build in the area for extra support).
If necessary, the perineum will be repaired with deep stitches into the muscle.
The vaginal incisions are closed with stitches and the vagina may be packed with gauze.

Question 32

Modified Oxford Scale pelvic floor muscle tone

Answer 32

The Modified Oxford Scale (MOS) was used to rate pelvic floor muscle contraction on a scale of 0–5
0 = no contraction; 
1 = minor muscle 'flicker'; 
2 = weak muscle contraction; 
3 = moderate muscle contraction; 
4 = good muscle contraction 
5 = strong muscle contraction.

Question 33

Sacrocolpopexy

Answer 33

Sacrocolpopexy is performed either through an abdominal incision or ‘keyholes’ under general anesthesia.
The vagina is first freed from the bladder at the front and the rectum at the back.
A graft made of permanent synthetic mesh is used
to cover the front and the back surfaces of the vagina. The mesh is then attached to the sacrum (tail bone). The mesh is then covered by a layer of tissue called the peritoneum that lines the abdominal cavity; this prevents the bowel from getting stuck to the
mesh.

Question 34

Colpocleisis

Answer 34

Colpocleisis involves the removal of vaginal epithelium and subsequent imbrication of the vaginal muscularis in anterior-to-posterior apposition, thereby creating a tissue septum of support.